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How to Start a CCM Program: A Comprehensive Guide

When your practice decides to launch a Chronic Care Management (CCM) program, you have the opportunity to enhance patient care and increase your revenue. But you probably also have questions. What resources will you need? How do you educate and enroll patients? What will the patient experience look like after enrollment? And how do you ensure you’re following CMS requirements? 

In this guide, we’ll offer insights into every aspect of starting a CCM program, from patient engagement to clinical notifications and ongoing enrollment. And if you’d like to learn more about the impact of CCM on your patients, check out our breakdown of how CCM improves health outcomes.

1. Explore Resources and Workflow for a CCM Program

The first step in launching a CCM program is understanding the resources your practice needs to have in place and the workflows you need to adopt. Practices often ask questions like: 

• Do we need to hire a full-time employee or employees to do CCM? 
• How many people need access to the CCM platform? 

The answer to these questions depends on patient volume, how many staff members you already have, and whether you’re working with a CCM partner. If your practice is running a CCM program internally, you will likely need to hire more staff to cover CCM calls, run the 24/7 nurse line, and maintain compliance and billing records. 

If you’re collaborating with a CCM company, you’re less likely to need new staff. However, your staff will still need to review patient eligibility lists and manage CCM clinical notifications from your CCM partner’s nurses, working under General Supervision.

You can expect to see 15-20 notifications per month for every 100 patients you enroll, and you’ll need enough internal employees to efficiently respond to those notifications.

It’s also critical to identify a champion who will help lead your implementation efforts. If you have a CCM partner to help with implementation, you will still need a designated internal leader to attend meetings, respond to emails, set timelines, and sign off on scope. 

2. Educate Patients

Your CCM program will only succeed if patients have a clear understanding of what Chronic Care Management is and how it could benefit them. Your CCM partners, your clinical staff, and your providers should all be prepared to educate patients. 

Here are a few methods ChartSpan recommends to engage and educate Medicare beneficiaries: 

Before Enrollment

Before enrollment, you can inform patients about your CCM program through a mix of phone, mail, and in-person communication. 

Full-service CCM companies can create phone messages to describe what CCM is and the benefits for patients. At ChartSpan, we offer technology for providers to record a ringless voicemail that patients can listen to whenever they prefer. For patients who prefer physical mail, many CCM vendors offer letters or postcards. 

The practice also plays a vital role in introducing patients to Chronic Care Management. Your practice can display materials like posters, brochures, and waiting room slideshows. If you have a CCM partner, they can help create these materials and train providers on what CCM is so they feel confident explaining the program to patients. 

Enrollment Calls

Patient enrollment calls involve:

• Explaining what CCM is
• Discussing the features of CCM, like monthly calls, care plans, and a 24/7 nurse line 
• Verifying the patient’s identity
• Explaining that Medicare pays for CCM, but deductibles and copays apply
• Asking the patient if they would like to enroll in CCM 
• Recording and archiving the call for at least 10 years

A patient must explicitly state they want to sign up for CCM before they can be enrolled. Some clinical staff are comfortable calling patients to enroll them, but most practices let trained enrollment specialists from a CCM company manage these calls. Enrollment specialists have experience with and time for enrollment calls, while clinicians frequently don’t. 

An effective CCM partner will also ask you for access to patients’ insurance and demographic information before the enrollment call. This allows the enrollment specialists to accurately communicate co-pay information and financial obligations. 

After Enrollment

Even after they choose to enroll in a CCM program, patients may still have questions about what the program includes. You’ll need to educate your patients or look for a CCM company who can help with education. Some options for patient education after enrollment include:

• A welcome email 
• A welcome packet with detailed information about what CCM is, frequently asked questions, and contact information for the nurse line or care coordinators
• A welcome call from the patient’s personal care coordinator 

A good CCM partner will have a plan for ensuring patients feel welcomed and informed as soon as they sign up for a CCM program. 

Ongoing Engagement

After patients enroll and receive their welcome call, it’s important to continue to educate and engage them throughout their CCM program. You or your CCM partner can accomplish this through monthly calls, texts, and updated, personalized care plans. 

A good CCM partner will also develop re-engagement plans to reach out to patients who’ve stopped answering calls. Re-engagement campaigns could include voicemails, texts, and emails. An ethical partner will automatically unenroll patients who haven’t engaged for a long period of time.

3. Review Patient Eligibility Lists

Determining which patients are eligible for CCM is an ongoing process. Patients continually become eligible: because they’ve joined Medicare or been diagnosed with a second chronic condition–or churn out of the program: because they’ve entered a full-time assisted care facility or passed away. 

Practices that run their own CCM program are responsible for pulling and reviewing patient eligibility lists. If you have a CCM partner, they can pull updated lists on a regular basis so that your providers can quickly review and approve them, as CMS guidelines require. The CCM partner will then reach out to the approved patients to determine whether they want to enroll. 

4. Establish Clinical Alignment for Your CCM Program

Clinical alignment ensures that your CCM program operates smoothly. If you have a CCM partner, you will need to set up an agreement about how you handle tasks like: 

• Pulling C-CDAs to gather patient eligibility data
• Initiating communication about specific patient needs through notifications
• Triaging calls and sending notifications about emergencies or urgent needs

A good CCM partner will establish a cadence you’re comfortable with for pulling C-CDAs and reviewing patient lists. They’ll also discuss how often your practice should check clinical notifications. (Most practices check notifications from ChartSpan’s clinical team roughly once per day.) 

Notifications should go two ways–in addition to seeing notifications from your CCM partner, you should be able to send them notifications when you’d like them to address a specific condition or concern with one of your patients.

Establishing a plan for triage calls is another essential element of CCM. Your partner should provide a fully staffed 24/7 nurse line with a clear triage protocol. In an emergency, the CCM nurses will contact 911 immediately. 

After the patient has received care, your CCM partner will notify your practice about what happened. You should set up a clear protocol for how you prefer to receive urgent notifications so your providers can quickly follow up. 

5. Plan Out the Patient Journey

A key component of CCM is understanding the patient journey. If you have a CCM partner, they should discuss what the patient journey will look like, including how they use care plans, care goals, screenings, and assessments.

ChartSpan uses SMART goal guidelines to help patients create their own care goals. We also have a program called ChartMarkers to inventory patients’ conditions, identify areas where they need additional care, and intervene where necessary. Some of the assessments we provide include:

• Clinical assessments
• Medication adherence assessments
• Quality assessments to identify care gaps
• Social Determinant of Health assessments

If one of these screenings reveals that a patient requires help with medication refills, transportation, access to healthy food, or other needs, their CCM coordinator can step in to connect them with resources. 

6. Set Goals for Success

To achieve success, practices must set patient enrollment and experience goals. If you have a CCM partner, they can help you create goals that are realistic. ChartSpan targets a 45% enrollment rate but practices a slow enrollment ramp-up over the first six months to reach this objective. 

The ChartSpan clinical team also typically sets goals for 100% of patients to have a care plan and for 100% of patients to receive clinical and medication adherence assessments. We consult with practices throughout the partnership to determine what other goals they would like to work toward. Whether you have a partner or are working independently, goal-setting is essential to ensure your CCM program is successful. 

Starting a CCM Program

By carefully considering enrollment, patient education and experience, and available resources, your healthcare practice can launch a CCM program that will provide excellent care for your patients without dramatically interrupting your workflows. 

Want to learn more about the impact CCM could have on your patients’ health? Check out our whitepaper on Chronic Care Management and patient outcomes.